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Idaho Medicaid Fraud Control Unit: 2018 Onsite Inspection

WHY WE DID THIS STUDY

OIG administers the Medicaid Fraud Control Unit (MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units' performance in accordance with the requirements of the grant. As part of this oversight, OIG conducts periodic reviews of all Units and prepares public reports based on these reviews.

HOW WE DID THIS STUDY

We conducted the onsite review of the Idaho MFCU in July 2018. Our review period covered Federal fiscal years (FYs) 2015-2017. We based our review on an analysis of data from seven sources: (1) Unit documentation; (2) financial documentation; (3) structured interviews with key stakeholders; (4) structured interviews with the Unit's managers and selected staff; (5) a review of a random sample of 68 case files that were open at any point during the review period; (6) a review of all convictions submitted to OIG for program exclusion and all adverse actions submitted to the National Practitioner Data Bank during the review period; and (7) observations of Unit operations.

WHAT WE FOUND

The Idaho MFCU reported 13 indictments, 11 convictions, 28 civil settlements and judgments, and nearly $5.3 million in recoveries for FYs 2015-2017. We found that the Unit operated in accordance with applicable laws, regulations, and policy transmittals. However, we made three findings involving the Unit's adherence to the MFCU performance standards. We found that: (1) although the Unit established a more frequent and robust practice for conducting periodic supervisory review of case files, it had not updated its policies and procedures manual to reflect the updated practices; (2) some of the Unit's cases had significant unexplained investigative delays; and (3) nearly a quarter of case files lacked documentation of periodic supervisory review.

WHAT WE RECOMMEND

We recommend that the Unit: (1) update its policies and procedures manual to reflect current Unit practices for periodic supervisory case file review; (2) take steps to ensure that investigation delays are limited to situations imposed by resource constraints or other exigencies and that delays are documented in the case management system; and (3) ensure that the case management system includes documentation of supervisory oversight. The Unit concurred with all three recommendations.